Prevalence of psychological distress and associated
factors in urban hospital outpatients in South
Africa.

Abstract:

Objective. The aim of this study was to assess the prevalence of
psychological distress and associated factors among outpatients in an
urban hospital in South Africa.

Method. A sample of 1 532 consecutively selected patients (56.4%
men and 43.6% women) from various hospital outpatient departments were
interviewed with a structured questionnaire.

Results. Based on assessment with the Kessler Psychological
Distress Scale, a measure of psychological distress, 17.1% of the
patients (15.5% of men and 19.4% of women) had severe psychological
distress. Logistic multiple regression identified no income, poor health
status, migraine headache and tuberculosis as significant factors
associated with severe psychological stress for men. For women the
factors identified were lower education, no income, having been
diagnosed with a sexually transmitted disease, stomach ulcer and
migraine headache.

Conclusion. The study found a high prevalence of psychological
distress among hospital outpatients in South Africa. Brief psychological
therapies for adult patients with anxiety, depression or mixed common
mental health problems treated in hospital outpatient departments are
indicated. Accurate diagnosis of co-morbid depressive and anxiety
disorders in patients with chronic medical illness is essential in
understanding the cause and optimising the management of somatic symptom
burden.

Common mental disorders such as depressive and anxiety disorders
are classified in the International Statistical Classification of
Diseases and Related Health Problems, 10th revision (ICD-10), (1) as
'neurotic, stress-related and somatoform disorders' and
'mood disorders'. Common mental disorders (CMDs), which
include depression, anxiety and somatoform disorders, make a significant
contribution to the burden of disease and disability in low- and
middle-income countries (LMICs). (2,3) These conditions are responsible
for up to 10% of the total global disease burden. (4) Based on recent
findings from World Health Organization World Mental Health surveys on
the global burden of mental disorders, the inter-quartile range (IQR:
25th-75th percentiles) of lifetime Diagnostic and Statistical Manual of
Mental Disorders, 4th edition, text revision (DSM-IV) disorder
prevalence estimates (combining anxiety, mood, externalising and
substance use disorders) was 18.1-36.1%. (5) At least one-third of all
patients seen in primary care in LMICs present with CMDs. The majority
of these are not recognised or are ineffectively treated. (4) Although
depressive and anxiety disorders are classified as separate diagnostic
categories in the ICD-10, (1) the concept of CMDs is valid for public
health interventions owing to the high degree of co-morbidity between
these disorders in primary care and the similarity in epidemiological
profiles and treatment responsiveness. (6)

Various studies have identified high prevalence rates of CMDs among
primary healthcare patients in LMICs, e.g. 23% probable cases in
Nicaragua, (7) 21.3% psychiatric disorders in Nigeria, (8) 23% major
depression, 24% panic disorder and 29% generalised anxiety disorder in
Lesotho, (9) and a prevalence of generalised anxiety and depressive
disorders of 23.9% in a community-based sample in South Africa. (10)

Increasing emphasis has been placed on the detection and treatment
of CMDs, particularly among patients seen in primary care settings. (4)
Hospital settings are a particularly valuable point of contact for the
delivery of brief interventions, because large numbers of patients
attend these facilities each year. The fact that little information
exists about CMDs or psychological distress among hospital outpatients
in South Africa prompted the study.

Aim of the study

The aim of this study was to assess the prevalence of psychological
distress and associated factors among outpatients in an urban hospital
in South Africa.

Methods

Sample and procedure

The sample included 1 532 subjects (56.4% men and 43.6% women)
consecutively selected from different hospital outpatient departments.
Universal screening of all presenting outpatients was utilised, whereby
all consecutive clients visiting outpatient departments were
interviewed. The study protocol was approved by the Research Ethics
Committee of the University of Limpopo (Medunsa Campus). Informed
consent was obtained from the patients who participated.

Measures

Demographic characteristics. A researcher-designed questionnaire
was used to record demographic information on participants' age,
gender, educational level, marital status, income and place of residence
(urban or rural).

The Kessler Psychological Distress Scale (K-10) was used to measure
global psychological distress, including significant pathology that does
not meet formal criteria for a psychiatric illness. (22, 23) This scale
measures symptoms over the preceding 30 days by asking: 'In the
past 30 days, how often did you feel: nervous; so nervous that nothing
could calm you down; hopeless; restless or fidgety; so restless that you
could not sit still; depressed; that everything was an effort; so sad
that nothing could cheer you up; worthless; tired out for no good
reason?' The frequency with which each of these items was
experienced was recorded using a 5-point Likert scale ranging from
'none of the time' to 'all the time. This score was then
summed, with increasing scores reflecting an increasing degree of
psychological distress. The K-10 has been shown to capture variability
related to nonspecific depression, anxiety and substance abuse, but does
not measure suicidality or psychoses. (24) This scale serves to identify
individuals who are likely to meet formal definitions for anxiety and/or
depressive disorders, as well as to identify individuals with
sub-clinical illness who may not meet formal definitions for a specific
disorder. (22) It is increasingly used in population mental health
research and has been validated in multiple settings (25) including
among pregnant women (26) and HIV-positive individuals in South Africa.
(27) We examined the K-(10) scale using ordinal categories for low,
moderate, high and very high psychological distress (scores of 10-19,
20-24, 25-29 and [greater than or equal to] 30, respectively) and as a
binary variable comparing scores of 0-29 versus [greater than or equal
to] 30. The internal reliability coefficient for the K-10 in this study
was Cronbach alpha = 0.89.

Alcohol consumption. The 10-item Alcohol Disorder Identification
Test (AUDIT) (28) assesses alcohol consumption level (3 items), symptoms
of alcohol dependence (3 items), and problems associated with alcohol
use (4 items). In South Africa a standard drink is 12 g alcohol. Because
the AUDIT is reported to be less sensitive at identifying risky drinking
in women than in men, (29) the cut-off point of binge drinking for women
(4 units) was reduced by one unit compared with men (5 units), as
recommended by Freeborn et al. (29) Responses to items on the AUDIT are
rated on a 4-point Likert scale from 0 to 4, for a maximum score of 40
points. Higher AUDIT scores indicate more severe levels of risk; scores
of 8 or more indicate a tendency to problem drinking. Cronbach alpha for
the AUDIT in this sample was 0.88, indicating excellent reliability.

Tobacco use. Two questions were asked about the use of tobacco
products: (i) 'Do you currently use one or more of the following
tobacco products (cigarettes, snuff, chewing tobacco, cigars,
etc.)?' (response options were 'yes' or 'no');
and (ii) 'In the past month, how often have you used one or more of
the following tobacco products (cigarettes, snuff, chewing tobacco,
cigars, etc.)?' (response options were once or twice, weekly,
almost daily and daily).

Perceived general health. Participants were asked: 'In
general, would you say your health is: excellent, very good, good, fair
or poor?' This measure was categorised based on participant
response (very good = excellent/very good, good = good, and poor = fair/
poor).

Patients were also given a list of chronic and communicable
illnesses such as hypertension, diabetes and sexually transmitted
diseases (STDs), and asked to indicate which of them they had been
diagnosed with.

Data analysis

Data were analysed using the Statistical Package for the Social
Sciences (SPSS) for Windows software application programme version 17.0.
Frequencies, means and standard deviations (SDs) were calculated to
describe the sample. Predictors of severe psychological distress were
identified using logistic regression analyses. Following each univariate
regression, multivariable regression models were constructed.
Independent variables from the univariate analyses were entered into the
multivariable model if significant at a level of p<0.05. Logistic
regression was conducted for men and for women separately. Cases with
missing data were excluded from the multivariable models. For each
model, the [R.sup.2] are presented to describe the amount of variance
explained by the multivariable model. Probability below 0.05 was
regarded as statistically significant.

Results

Sample characteristics

Of the 1 713 hospital outpatients approached, 1 532 agreed to
participate (89.4% response rate). The final sample included 1 532
(56.4% men and 43.6% women) consecutively selected from different
hospital outpatient departments. Their mean age was 36.1 years (SD 11.6,
range 18-77 years). Almost two-thirds (63.8%) of the participants had
never been married, almost half (48%) had grade 12 or higher education,
32.6% had a formal salary as main household income, and 80.1% lived in
an urban area. Forty per cent of the hospital outpatients had chronic
conditions and 60% were general hospital outpatients, 57.8% rated their
health as excellent or very good, 24.2% used tobacco products daily or
almost daily, and 34.9% scored 8 or more on the AUDIT indicating
hazardous or harmful alcohol use. With regard to previously diagnosed
conditions, 30.2% reported migraine headaches, 26.1% lower back pain,
19.3% hypertension, 17.3% arthritis, 17.3% stomach ulcer, 8.3% diabetes,
7.6% STD, 7.3% tuberculosis and 7.3% depression (Table 1).

Psychological distress

Overall 17.1% of the patients had scores on the K-10 indicating
severe distress; this figure was significantly higher in women (19.4%)
compared with men (15.5%). Moderate distress was reported by 14%, mild
distress by 18.6% and no significant distress by 50.3% (Table 2).

Predictors of psychological distress

Univariate analyses showed that among men, lower education, no
income, poor self-rated health status, daily or almost daily tobacco
use, and having been diagnosed with a stomach ulcer, migraine headache,
lower back pain, high cholesterol, arthritis or tuberculosis were
associated with severe psychological distress; and among women, severe
psychological distress was associated with older age, lower education,
no income, being a chronic disease hospital outpatient, poor self-rated
health status, and having been diagnosed with hypertension, a sexually
transmitted disease, migraine headache, lower back pain, high
cholesterol, diabetes or tuberculosis. Multivariable analysis showed
that among men no income, poor self-rated health status, daily or almost
daily tobacco use, and having been diagnosed with migraine headache or
tuberculosis remained significantly associated with severe psychological
distress, and that for women lower education, no income, and having been
diagnosed with a sexually transmitted disease, stomach ulcer or migraine
headache remained significantly associated with severe psychological
distress (Table 3).

Discussion

A high prevalence of severe (17.1%) and moderate (14.0%)
psychological distress was identified in this study of a large sample of
hospital outpatients in South Africa. This finding is comparable with
prevalence rates of psychological distress or CMDs in other LMICs
(Nicaragua 23%, (7) Nigeria 21.3%, (8) Lesotho major depression 23%,
panic disorder 24%, and generalised anxiety disorder 29%). (9)

In concurrence with other studies this study found an association
between severe psychological distress and female gender. (8) low
socio-economic status (lower education, no income, (10,11,13) daily or
almost daily tobacco use, (14,30) and having been diagnosed with chronic
diseases including stomach ulcer, (19) migraine headache, (19) lower
back pain, (20) hypertension, (18) and communicable diseases including
tuberculosis (21) and STDs. (31) In a large Canadian community study,
sexually transmitted infections (STIs) among women also increased the
risk of depression. (32) The diagnosis of an STI may contribute to the
development of depression. (32)

Study limitations

Caution should be taken when interpreting the results of this study
because of certain limitations. As this was a cross-sectional study,
causality between the compared variables cannot be concluded. A further
limitation was that all variables were assessed by self-report and
desirable responses may have been given.

Conclusion

The study found a high prevalence of psychological distress among
hospital outpatients in South Africa. Brief psychological therapies for
adult patients with anxiety, depression or mixed common mental health
problems treated in hospital outpatient departments are indicated. (33)
Accurate diagnosis of co-morbid depressive and anxiety disorders in
patients with chronic medical illness is essential in understanding the
cause and optimising the management of somatic symptom burden. (34)

Acknowledgement. The study was funded by the Directorate General
for Development Cooperation (DGDC) through the Flemish Interuniversity
Council (VLIR-UOS).